Nursing Care Plan

Cues Actual/Potential Expected Outcome Nursing Orders Rationale Evaluation Formatted Table
Nursing (SMART) (OME)
Diagnosis

S – “Di ko kaubra Activity After 2 days of -monitor vital signs and -to help determine After 2 days of
sakong mga intolerance nursing intervention, recorded. patients current health intervention the
hilimuon kay di ko related to the patient will be status and evaluate patient is still can’t
makagiho gid kay decreased energy able to maintain effectiveness of perform activity by
sakit samot akong requirements as activity level with in nursing intervention self and need
likod og mugiho evidenced by capabilities as rendered. assistance in doing
ko” as verbalized decreased muscle evidenced by normal -monitor intake and -to evaluate proper activity.
by the patient. strength. vital signs during output as order. functioning of her
activity, as well as kidney in relation to
absence of weakness, her present condition.
O– pain, and difficulty -assess ability to -to determine the
accomplishing tasks. perform ADL. capacity of patient in
 Weak in performing ADL.
appearance -assess physical mobility -to know if there’s any
 Cannot status. changes on patient’s
perform condition specifically
ADL’s alone on physical aspect.
 With limited -assist patient to do -to maximize full
ROM active ROM exercise strength.
 Muscle like flexing of both
strength extremities.
weakness -promote rest and -to conserve energy.
 Braiden comfort.
scale: 13 -emphasize importance -to promote
of frequent ambulation. circulation.
-encourage to verbalize -to determine other
feelings and concern factors that might
regarding her present contribute to patient’s
condition. present condition.
 -emphasize importance -to achieve therapeutic
of compliance to effect of medication
treatment and and for fast recovery.
medication.

Reference:www.scribd.com and nurseslabs.com

Nursing Care Plan

Cues Actual/Potential Expected Outcome Nursing Orders Rationale Evaluation Formatted Table
Nursing (SMART) (OME)
Diagnosis

“gasakit gid yah Acute pain After 2 days of -perform a -pain is a subjective After 2 days of
ang akon nga likod, related to nursing intervention comprehensive experience and must nursing intervention,
kung mag giho lang fracture as the patient will be assessment of pain to be described by the the patient
ko gamay kay sakit evidenced by able to relieve the include location, client in order to plan verbalized pain scale
sakit na dayun” as pain scale of 7/10. pain and move her characteristics, onset, effective treatment. 5/10.
verbalized by the back constantly. duration, frequency,
patient. quality, intensity or
severity, and
precipitating factors of
-facial grimace pain.
-pain scale : 7/10 -assess vital signs, -changes in the V/S
With limitations in noting tachycardia, often indicate acute
movements. hypertension, and pain and discomfort.
increase respiration,
even if client denies
pain.
-reduce or eliminate -personal factors can
factors that precipitate influence pain and
or increase pain pain intolerance.
experience.
-elicit behaviors that are -relaxation techniques
conditioned to produce help reduce skeletal
relaxation, such as deep muscle tension, which
breathing, yawning will reduce the
abdominal breathing, intensity of pain.
music therapy, or
peaceful imaging.
-create a quiet, no -comfort and quite
disruptive environment atmosphere promote a
 with dim lights and relaxed feeling and
comfortable permit the client to
temperature when focus on the relaxation
possible. technique rather than
external distraction.

-instruct client to report -unrelieved pain can

any improvement/ create other problems
exacerbation of pain. such as anger, anxiety,
immobility,
respiratory problems
and delay in healing.
-encourage -only client can judge
verbalization about the level and distress
feelings of pain. of pain, pain
management should
be a team approach
that includes the
client.
-encourage mobilization -to promote
of back and extremities. circulation to prevent
excessive tissue
pressure.

Reference:www.scribd.com and nurseslabs.com